Every treatment has two questions attached to it. The first is how well it works. The second is what it costs the person receiving it: in recovery time, in risk, in catheters and stents and hospital days, in the chance of a side effect that lasts. Medicine is very good at asking the first question and often forgets the second. At NYMD Center we ask them in the other order. Before we decide whether a treatment is effective enough, we ask what it will cost you, and whether something that costs less will do the job.
That is the whole philosophy, and it shapes how the practice is built. Here is what it looks like in practice.
Cost is not only money
When we say cost, we mean the sum of everything a treatment takes from a patient. A week off work. A catheter for three days. A stent that stays in for two weeks and makes every step uncomfortable. General anesthesia. A hospital stay, with the infections and disruptions that come with it. A small but permanent chance of incontinence or erectile dysfunction. A scar. The need for a second procedure years later.
Two treatments with the same chance of success are not equal if one of them takes a month from your life and the other takes an afternoon. Neither are two treatments where the more invasive one works somewhat better but carries a much larger burden. The right comparison is always benefit against cost, and the patient is the one who gets to weigh them, which means the patient has to be told both.
Prostate artery embolization before laser surgery
An enlarged prostate can be treated by removing tissue through the urethra with a laser or a resectoscope. It works well. It also usually requires anesthesia and a catheter afterward, carries a risk of bleeding, involves a recovery measured in weeks, and commonly leaves men with permanent changes to ejaculation. It is a reasonable treatment. It is not, in our view, the first one.
Prostate artery embolization reaches the prostate through a small puncture in the wrist or groin and blocks the arteries feeding it, so the gland shrinks over the following weeks. There is no instrument in the urethra, no catheter for most men, no general anesthesia, and ejaculation is typically preserved. Recovery is a few days. Relief is more gradual than with surgery, and some men will still need surgery later, but for many the question never comes up again. So we offer embolization first, and reserve the laser for men whose anatomy or symptoms call for it or who did not get enough relief.
Shock wave lithotripsy before ureteroscopy
Kidney stones can be broken with sound waves from outside the body, or a scope can be passed up the ureter to fragment and remove them directly. Ureteroscopy is more certain to clear the stone in one session. It also usually leaves a ureteral stent in place for days to weeks, and anyone who has had one will tell you the stent was worse than the stone. Shock wave lithotripsy is done without any instrument inside the body, usually without a stent, and most patients go home and resume normal life the same day. It may need repeating, and it is a poor choice for some stones. But for a stone of the right size, hardness and location, it costs the patient far less, and that is why it is our first offer.
Embolization before open varicocele repair
A varicocele is a cluster of enlarged veins around the testicle that can cause pain, lower sperm counts and shrink the testicle. The traditional repair is a small operation through the groin or abdomen to tie off the veins. Embolization does the same job from inside the vein: a catheter is passed through a puncture, the abnormal veins are closed off, and the patient walks out the same day with a bandage. No incision, no general anesthesia, and none of the risk to the testicular artery or the lymphatics that the surgical approach carries. Surgery still has a place when the veins cannot be reached with a catheter, but it is not where we start.
The office instead of the hospital
The place a procedure is done is part of its cost. Hospitals are built for very sick people, and a healthy person having a small procedure absorbs their delays, their exposure to infection, their overnight stays and their facility fees. We built an office-based surgery center so that the procedures above, along with vasectomy, circumcision, cystoscopy, prostate biopsy, bladder Botox and many others, are done in our own rooms, with our own staff, and with a separate anesthesiologist when propofol sedation is needed. You arrive, have the procedure, recover in a chair, and go home the same day. There is no facility fee because there is no facility beyond the one you are already sitting in.
When the invasive option is right
Least invasive first does not mean least invasive only. Some prostates are too large or too obstructed for embolization to help. Some stones are too hard, too large, or in a place shock waves cannot reach. Some varicoceles have anatomy that cannot be catheterized. Some cancers need to be removed. When the smaller option has a low chance of working, offering it first only adds a failed procedure to the patient's cost, and the honest recommendation is the bigger one. The principle is not to avoid surgery. It is to make sure that when surgery happens, it happens because it was the right choice and not because it was the only one considered.
How to ask your doctor
You do not need to know the options to ask about them. Three questions will do. Is there a less invasive way to treat this, and if so, why are we not starting there? What will this treatment cost me in recovery, and which of its risks would not go away? And if the less invasive option does not work, does it close the door on the bigger one, or can we still do it later? A good physician will welcome the questions. If the answers are vague, get a second opinion.
We wrote this because it is the question we most want patients to bring us. You can read more about prostate artery embolization and kidney stone treatment on this site, and our dedicated prostate site, 1prostate.com, goes deeper on how embolization compares with surgery.
Questions patients ask
Does least invasive first mean you avoid surgery?
No. It means surgery has to earn its place. When the smaller option has a good chance of working, we offer it first and keep the larger one in reserve. When the smaller option is unlikely to help, offering it anyway only adds a failed procedure to what you go through, and the honest recommendation is the bigger one. The principle is about the order in which options are considered, not about ruling any of them out.
If the less invasive treatment fails, can I still have the more invasive one?
In the examples we use, yes. Prostate artery embolization does not prevent later laser surgery, shock wave lithotripsy does not prevent ureteroscopy, and varicocele embolization does not prevent surgical repair. That is one of the questions we suggest asking any doctor: does starting small close the door on the larger option, or does it stay open? For most of what we treat, the door stays open.
Why do procedures in the office rather than a hospital?
Because the setting is part of what a procedure costs you. A healthy person having a small procedure in a hospital absorbs its delays, its exposure to infection, its overnight stays and its facility fees. Our office-based surgery center does the same procedures in our own rooms, with a separate anesthesiologist when sedation is needed, and you go home the same day.